Align Spine Chiropractic & Wellness

10 Union St #2D,
Natick, MA 01760

Home
Patient Center
About Us
Services
Blog
Contact Us
- Appointment Request

(508) 545-6789 Schedule your visit

Home
Patient Center
About Us
Services
Blog
Contact Us
- Appointment Request

(508) 545-6789 Schedule your visit

Home

Patient Center

Online Forms

Neck Pain Questionnaire

Neck Pain Disability Index

First Name*

Last Name*

Email *

Contact # *

Pain Intensity

A - I have no pain B - Pain is very mild at the moment C - Pain is moderate at the moment D - Pain if fairly severe at the moment E - Pain is very severe at the moment F - Pain is the worst imaginable at the moment

Personal Care (washing, dressing, etc.)

A - I can look after myself normally without causing extra pain B - I can look after myself normally, but it causes extra pain C - It is painful to look after myself and I am slow and careful D - I need some help, but manage most of my personal care E - I need help every day in most aspects of self care F - I do not get dressed, I wash with difficulty and stay in bed

Lifting

A - I can lift heavy weights without extra pain B - I can lift heavy weights, but it causes extra pain C - Pain prevents me from liting heavy weights off the floor, but I can manage if they are conveniently positioned (ex. on a table) D - Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned E - I can lift very light weights F - I cannot lift or carry anything at all

Reading

A - I can read as much as I want to with no pain in my neck B - I can read as much as I want to with slight pain in my neck C - I can read as much as I want to with moderate pain in my neck D - I cannot read as much as I want because of moderate pain in my neck E - I cannot read as much as I want because of severe pain in my neck F - I cannot read at all

Headaches

A - I have no headaches at all B - I have slight headaches which come infrequently C - I have moderate headaches which come infrequently D - I have moderate headaches which come frequently E - I have severe headaches which come frequently F - I have headaches almost all the time

Concentration

A - I can concentrate fully when I want to with no difficulty B - I can concentrate fully when I want to with slight difficulty C - I have a fair degree of difficulty in concentrating when I want to D - I have a lot of difficulty in concentrating when I want to E - I have a great deal of difficulty in concentrating when I want to F - I cannot concentrate at all

Work

A - I can do as much work as I want to B - I can only do my usual work, but no more C - I can do most of my usual work, but no more D - I cannot do my usual work E - I can hardly do any work at all - I cannot do any work at all

Driving

A - I can drive my car without any neck pain B - I can drive my car as long as I want with slight pain in my neck C - I can drive my car as long as I want with moderate pain in my neck D - I cannot drive my car as long as I want because of moderate pain in my neck E - I can hardly drive at all because of severe pain in my neck F - I cannot drive my car at all

Sleeping

A - I have no trouble sleeping B - My sleep is slightly disturbed (less than 1 hr sleepless) C - My sleep is mildly disturbed (1-2 hrs sleepless) D - My sleep is moderately disturbed (2-3 hrs sleepless) E - My sleep is greatly disturbed (3-5 hrs sleepless) F - My sleep is completely disturbed (5-7 hrs sleepless)

Recreation

A - I am able to engage in all of my recreational activities with no neck pain B - I am able to engage in all of my recreational activities with some pain in my neck C - I am able to engage in most, but not all of my recreational activities because of pain in my neck D - I am able to engage in a few of my recreational activities because of pain in my neck E - I can hardly do any recreational activities because of pain in my neck F - I cannot do any recreational activities at all

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

Align Spine Chiropractic & Wellness

10 Union St #2D,
Natick, MA 01760 US

Monday:

9:00 am - 12:30 pm

2:30 pm - 6:00 pm

Tuesday:

7:30 am - 12:30 pm

2:30 pm - 4:00 pm

Wednesday:

9:00 am - 12:30 pm

2:30 pm - 6:00 pm

Thursday:

7:30 am - 12:30 pm

2:30 pm - 4:00 pm

Friday:

7:30 am - 12:00 pm

Saturday:

Closed

Sunday:

Closed

CONTACT US

We hope to see you soon

Name*

Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

--mi

Align Spine Chiropractic & Wellness

10 Union St #2D
Natick, MA 01760, US

(508) 545-6789

[email protected]

10 Union St #2D,
Natick, MA 01760

(508) 545-6789

Meet the Doctor
Services
Health Resources
New Patients
Appointment Request

Join our custom newsletter

Stay informed—sign up for our chiropractic-specific newsletters to receive health tips, local event updates, and the latest innovations.

Email *

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

Admin Log In
Site Map